Health inspection·April 10, 2025

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record reviews, and staff interviews, it was determined that the facility failed to review and revise the resident care plan to reflect the resident's current status for three of 16 residents reviewed (Residents 5, 36, and 42). Findings include: Review of Resident 5's clinical record revealed diagnoses that included protein-calorie malnutrition (insufficient protein intake or protein deficiency) and bipolar disorder (mental illness that brings severe high and low moods and changes in sleep, energy, thinking, and behavior). Observations made on April 7, 2025, at 10:08 AM; April 9, 2025, at 11:00 AM; and on April 10, 2025, at 9:31 AM, revealed that the mattress on Resident 5's bed had built-up sides, and fall mats were present on both sides of the bed. Review of Resident 5's current care plan revealed a focus area related to her risk of falls due to weakness with a goal to be free of falls through the next review date. Review of the related interventions failed to note the use of fall mats or a specialty mattress to reduce falls and/or injury related to falling. In email correspondence received from the Director of Nursing (DON) on April 10, 2025, at 10:39 AM, she revealed that Resident 5 was evaluated and found appropriate for fall mat and specialty mattress use, and that these interventions would be added to her care plan. Review of Resident 36's clinical record revealed that she was admitted to the facility on [DATE], with a primary diagnosis of syncope (fainting or sudden loss of consciousness mainly caused by reduced blood supply to the brain) and collapse (a sudden loss of strength or support), as well as, generalized muscle weakness, and unsteadiness on feet. Review of Resident 36's clinical record progress notes revealed that on February 14, 2025, at 3:47 PM, she had a syncopal episode, which resulted in staff having to lower her to the floor. In addition, she was transferred to the hospital for an evaluation at the request of Resident 36's Representative. Further review of Resident 36's clinical record progress notes revealed that on March 4, 2025, at 8:30 AM, she had an unresponsive episode while in the dining room. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 6 Event ID: 395876 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395876 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cumberland Crossings Retirement Community 1 Longsdorf Way Carlisle, PA 17013 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)